Tag Archives: covid19

Estrogen & COVID-19 Severity in Women

Growing clinical evidence reveals that the intensity of COVID-19 infection and incidence of related complications are more prominent in male patients. Current data suggests that men experience a greater risk than women for more severe COVID-19 symptoms and poorer outcomes regardless of their age. These burgeoning findings signal that sex may function as a determinant of COVID-19 infection severity.

While the body of evidence examining sex differences in virus outcomes is lacking, researchers believe the functional modulation of angiotensin-converting enzyme 2 by estrogen may explain disparities in morbidity and mortality. Further reasons for higher male sex-specific COVID-19-related mortality are likely multi-fold and may include lifestyle differences such as higher rates of tobacco smoking and alcohol consumption as well as innate immunity. The mounting evidence suggesting sex-based differences in clinical outcomes emphasizes the need for an assessment of sex-specific hormone activity – in particular, estrogen – in COVID-19 pathogenesis.

Sex-Specific Differences in COVID-19 Outcomes 

A recent study conducted by researchers at the Wake Forest Baptist Medical Center attempts to elucidate the mechanisms underlying these notable differences. Led by Leanne Groban, MD, professor of anesthesiology at Wake Forest School of Medicine, a team of researchers conducted a review of published literature to determine whether sex plays a role in COVID-19 outcomes by examining pre-clinical data on sex-specific hormone activity.

Beneficial Impact of Estrogen

The study’s authors reported that angiotensin-converting enzyme 2 – attached to cell membranes in heart, arteries, kidneys, and intestines – acts as a cellular receptor of the coronavirus responsible for COVID-19 infections and helps the virus gain access to cells of those organ systems. According to the researchers, their review also pointed to estrogen’s impact on ACE2 levels in the heart; the hormone lowered ACE2 levels. This may modulate the severity of COVID-19 in women, while higher levels of ACE2 present in tissues could account for why the disease presents worse in men.

“We know that coronavirus affects the heart and we know that estrogen is protective against cardiovascular disease in women, so the most likely explanation seemed to be hormonal differences between the sexes,” said the lead author of the review, Dr. Groban told ScienceDaily in an interview.

“We hope that our review regarding the role of estrogenic hormones in ACE2 expression and regulation may explain the gender differences in COVID-19 infection and outcomes and serve as a guide for current treatment and the development of new therapies,” Groban said.

An enhanced understanding of the role of estrogenic hormones in ACE2 expression and regulation may not only help uncover potential mechanisms that explain sex differences in COVID-19 clinical outcomes, but also guide future disease management techniques and spur the discovery of novel therapeutic methods.

Impact of COVID-19 Isolation and Social Distancing on Mental Health

As a method of novel coronavirus disease transmission suppression and an attempt to reduce the risk of infection, social restrictions – such as social distancing and sheltering in place – have been put into place and remain active in the majority of the United States. Such measures have isolated many older adults at home, leaving them with limited contact and social interaction for the duration of the outbreak. As evidenced by global statistics revealing higher death rates among this demographic, the COVID-19 pandemic has been disproportionately affecting older adults.

Current literature suggests that social interaction is an integral component of mental health and wellbeing, while loneliness has been associated with morbidity and mortality in prior research. While the isolating effects of social distancing measures have been felt acutely by the entire population and may be especially profound in older demographics, relatively little scientific evidence on the subject is currently available. A recent study published in the Pan American Journal of Public Health aimed to provide further information on the implications of social distancing measures on patient mental health.

Coping with Coronavirus Isolation

A team of researchers aimed to examine the impact of isolation and social distancing among adults aged 60 and above during the COVID-19 outbreak in the United States. To conduct this analysis, the study’s authors asked convenience sampling respondents to complete a web-administered survey exploring the effects of social distancing on mental health factors, including loneliness, stress, and behavioral changes. In total, data from 833 responses from participants aged 60 and above were included in the sample.

Effects of Social Distancing on Older Patients

Of the total survey respondents, 36% reported being stressed while nearly 43% reported feelings of loneliness. Approximately one-third of participants reported feelings of increased loneliness during the social distancing period specifically. Respondents also reported engaging in more solitary activities and fewer in-person activities, using email and text messages more than usual, and spending more time using technology than before.

The study’s authors noted significant differences between younger patients aged 60-70 and those above the age of 71; changes in physical activity, drinking, recreational drug use, and sleeping pattern were found to differ by age. Participants over the age of 71 showed more resiliency with 74% experiencing little to no stress, according to the authors.

“That’s where older adults have a strength,” lead researcher and clinical associate professor at the University of Georgia’s Institute of Gerontology Kerstin Emerson told HealthDay. “They have life experience and coping mechanisms that we don’t often give them credit for, but that’s part of their wisdom. We can really turn to older adults as examples of how to manage and live through bad periods of history.”

Furthermore, two-thirds of survey respondents reported using more social media than they would before the pandemic began revealing that older adults are actively engaging in other forms of social connection and becoming increasingly comfortable online. However, for some older individuals remote connections may be more difficult to achieve due to a lack of internet or smart device access; Emerson noted that her team’s results don’t reflect the most vulnerable populations socially isolated in rural areas or those without sufficient economic resources.

As social distancing regulations and isolation measures persist across the globe, it is important to consider the effects of these strategies on mental health – especially among older adults in the United States. The latest findings indicate the potential adverse psychiatric effects associated with continued shelter-in-place practices and highlight the need for increased mental health screening among vulnerable populations at this time.

Return to Non-Emergent Care: Common Reopening Challenges Facing Your Practice

As practices begin to reopen to serve the needs of patients and begin delivering non-emergent care, many physicians may be wondering what the appropriate protocols in the pandemic environment are and how best to support their patients at this time. In addition, the new clinical setting presents its own set of challenges that require a strategic and unified approach. Physicians must now balance the need for in-person visits – which are crucial for critical medical care and revenue generation – with the risk of COVID-19 spread. Telemedicine has proven an adequate solution to patient management, however, it may not be a sufficient method of delivering care for all patients and some demand in-office appointments despite the ongoing virus spread.

Dr. Sachin Dave, an internist of the Indiana Internal Medicine Consultants stresses the importance of educating patients and communicating the risks to them. “My older patients actually insist on coming to see me in person,” he told Medscape in an interview, “I have to tell them it’s not safe.” Minimizing risk is paramount in the process of reopening medical practices across the United States and the globe; physicians must weigh the risks of increasing patient volume with patient and staff safety.

To assist healthcare practitioners in safely transitioning back to in-person care, Medscape has outlined some common challenges they may face in the reopening process, and how best to mitigate them.

1.     Unclear or Nonexistent Policies and Protocols

While physicians and other staff members may be aware of the COVID-19 prevention rules implemented to help mitigate virus transmission, patients need to be made aware of them preferably in a readily available document; it is important to develop formal protocols for all to follow to minimize confusion and ensure safety.

This includes enforcing mandatory mask wear for both staff and patients, setting up facilities in accordance with social distancing guidelines, having alternate waiting areas or asking patients to wait in their cars if the space gets too crowded, and other protective strategies.

Ensure all patients understand and agree to adhere to your new policies before they come in; in addition, they should be triaged over the phone per CDC guidelines before attending an in-office visit. Without a formal framework, refusing care or assessment of patients who do not comply with guidelines may lead to patient abandonment claims, making clear policies paramount at this time.

2. Too Many Patients, Too Soon

According to data from the Medical Group Management Association (MGMA), practices report an average 55% decrease in revenue and 60% decrease in patient volume since the COVID-19 crisis began. As a result, experts believe practices may be tempted to ramp up capacity immediately to restore prior patient volume. However, this period requires slow and carefully implemented safety protocols.

Physicians and their patients are encouraged to take advantage of telehealth services while they remain reimbursable at parity. The elevated demand for online care is forecasted to continue growing as more patients become comfortable with the technology and services become more advanced. While some doctors want to see an overload of patients immediately upon reopening, there has to be a limit on the number of patients coming into an office as welcoming too many patients too fast can have dire consequences.

3. Lack of Communication

Another potential pitfall is under-communication; patients may not be aware that your practice has reopened or plans to do so. It is important to consistently update your practice’s website, send out letters or newsletters to patients, maintain phone and email contact, post signs explaining reopening protocols, and keep everyone in the loop. The CDC has provided phone advice line tools that practices can adapt to their needs to keep patients informed.

Instead of under-communicating, physicians are encouraged to over-communicate to their patients as well as their staff, making sure they are made aware of the extra precautions being taken to prioritize their health and safety. Practice staff should also be aware of policy changes to minimize confusion.

Experts believe that practices can emerge stronger from the pandemic if they promote strong patient education and build up goodwill at this time. Leverage the patient portal, using it as a trusted resource to inform patients about COVID-19 and preventative measures being taken at your practice.

4. Inadequate Staff Training

Some staff members may be apprehensive about returning to work as a result of virus-related fears. Clear guidance is needed to ensure safety, manage expectations, and offer flexibility with scheduling to address potential challenges before they occur.

Properly training staff members is essential to their safety and that of your patients; specific guidelines for staff – such as designating eating areas, staggering appointments – should be clearly articulated and readily available. Many staff members may not be used to donning and removing personal protective equipment or wearing masks when working with patients. Training staff members will help reassure patients that safety protocols are being adhered to.

5. Neglecting Documentation

With the changing standard of care, a consistent workflow is paramount. This includes proper documentation, communication with staff and patients, and the use of established systems aimed at mitigating COVID-19 risk. Experts recommend keeping an administrative file used to track new protocols, policies, and any incidents or breaches for future use.

6. Forgetting About Personal Mental and Physical Health

Physicians should be cognizant of the high potential of burnout and mental health state  of their staff, their colleagues, and themselves. Mental exhaustion as a result of the persisting COVID-19 crisis and ongoing societal tensions is affecting all members of the population and has the potential to carry over to medical practices. To protect their mental and physical health as well as that of their staff members, physicians are encouraged to prioritize maintaining a positive culture at their practice – one in which everyone feels safe, taken care of and helps each other.

Practices and healthcare professionals located in areas which have deemed non-emergent care facilities eligible to reopen safely should take into consideration the aforementioned challenges and common pitfalls that may impede a smooth return to routine care. For those in search of comprehensive reopening recommendations and guidelines, The Doctors Company has developed an extensive checklist outlining the necessary steps for transitioning to in-person care – accessible here.